Employees in Chicago with long term disability insurance coverage frequently ask whether the insurer can force them to be undergo an independent medical examination by the doctor of the insurance company’s choice. Often the answer is yes. But not always. Most policies contain clauses stating you must provide proof of claim, and that you must comply with a reasonable request, including to be examined by a doctor of the insurer’s choosing. There are a couple circumstances where you may not have to comply with the request.
Some insurers make voluminous demands of claimants in the name of “proof of claim,” just to set up a litigation defense that you did not cooperate or provide proof of claim. Most policies limit the requests to that which is reasonable and necessary to decide the claim. If your insurer already sent you to several examinations, and the results of those have been consistent, there is a good chance you may not need to attend an additional one.
Another instance where you may not need to attend is where the insurer failed to make the request in time to complete its review within the time ERISA and its regulations allow. For example, in Chapin v. Prudential Insurance Co. of America, No. 19-cv-1256, 2021 WL 1090749 (W.D. Wash. Mar. 22, 2021), Prudential took past the 90 days allowed to conduct its appeal review. It claimed the time was tolled because Chapin did not provide necessary evidence, but he in fact provided the evidence Prudential claimed it needed. Right before the end of its 90 days allowed under 29 C.F.R. § 2560.503-1, Prudential demanded Chapin attend an Independent Medical Examination. Chapin immediately filed suit under ERISA § 502(a) seeking benefits and relief for breach of fiduciary duty. The Court ruled in favor of Chapin, notwithstanding Prudential’s argument it needed the independent medical examination.
If you have claim for long-term disability insurance benefits and the insurer has demanded you attend an independent medical examination, you should consult an experienced ERISA long-term disability lawyer about your rights and obligations under the insurance policy.